多模式镇痛在双侧人工全膝关节置换术患者的应用

Application of multimodal analgesia in patients undergoing bilateral total knee arthroplasty

目的观察双侧人工全膝关节置换术(TKA)后多模式镇痛效果。方法 45例行双侧TKA手术患者随机均分为三组,术前均静脉给予帕瑞昔布40mg,术中膝关节后关节囊予局麻药浸润。术后镇痛:Ⅰ、Ⅱ组采用舒芬太尼0.2、0.3μg/kg患者自控静脉镇痛(PCIA);Ⅲ组给予舒芬太尼0.2μg/kg PCIA复合双侧股神经单次阻滞。记录术后6、12、24、48h静息时视觉模拟疼痛评分(RVAS)和改良Bromage肌力评分、术后24、48h膝关节主动功能训练时视觉模拟疼痛评分(IVAS)以及镇痛药追加次数和不良反应。结果Ⅱ、Ⅲ组术后6、12、24h的RVAS评分和术后24h的IVAS评分低于Ⅰ组(P<0.05),Ⅲ组术后6、12h的改良Bromage肌力评分高于Ⅰ、Ⅱ组(P<0.05),Ⅱ组恶心、呕吐及尿潴留次数多于Ⅰ、Ⅲ组(P<0.05),Ⅰ组镇痛药追加次数多于Ⅱ、Ⅲ组(P<0.05)。结论在静脉给予非甾体药物和部分膝关节腔内局麻药阻滞基础上,双侧TKA术后采用舒芬太尼复合双侧股神经阻滞可以提供更好的镇痛效果。

Objective To observe the analgesic efficacy of multimodal analgesia in the patients undergoing bilateral total knee arthroplasty（TKA）. Methods Forty-five patients undergoing bilateral TKA were given parecoxib 40 mg intravenously before operation and joint capsule local injection of local anesthetics at the end of surgery. Postoperative patient-control analgesia（PCI） was performed with sulfentanyl 0.2μg/kg （group A）, sulfentanyl 0. 3 μg/kg （group B） or sulfentanyl 0. 2 μg/kg combined with bilateral femoral nerve blocks （group C）. Visual analogue score at rest （RVAS） and modified Bromage motor score were evaluated at 6,12,24 and 48 hours after operation. VAS pain score at active joint exercise（EVAS） at 24 and 48 hours after operation were recorded. The frequency of additional analgesics and adverse responses were recorded as well. Results RVAS at 6, 12 and 24 hours and EVAS at 24 hours after operation were lower in groups of B and C than those in group A （P〈0. 05）. Modified Bromage motor score at 6 and 12 hours after operation was lower in group C than that in groups of A and B（P〈0. 05）. The incidence rates of nausea, vomiting and uroschesis were higher in group B than those in groups of A and C（P〈0. 05）. The frequency of additional analgesics was higher in group A than that in groups of B and C（P〈0. 05）. Conclusion Based on parecoxib 40 mg intravenously before operation and joint capsule local injection of local anesthetics at the end of surgery,postoperative PCI with sulfentanyl 0.2 μg/kg eonbined with bilateral femoral nerve blocks can provide better analgesia in the patients undergoing bilateral TKA.